Radical prostatectomy involves a rejoining of bladder to urethra and a catheter for 1-3 weeks. If the new joint is not splinted with a catheter it will close due to scarring. Additionally urine needs an outlet (provided by the catheter).
Radical prostatectomy is the most common oncological procedure performed by urologists and leaving an indwelling urethral catheter is considered mandatory after open or laparoscopic radical prostatectomy to allow anastomotic healing. The duration of catheterization averages about 5-7 days in most minimally invasive series. However, urinary catheterization is a source of infection, discomfort, anxiety and embarrassment to the patient undergoing radical prostatectomy. Definitive morbidity, such as discomfort, bacteriuria and urethral stricture, is also directly associated with the time a catheter is left in place after surgery.
There have been no published clinical trials of radical prostatectomy performed without a urethral catheter. In gynecological and vascular procedures, a suprapubic catheter has been shown to be better than a urethral catheter. In a review of 5 randomized control trials comparing suprapubic catheter and urethral catheter in colorectal surgery it was demonstrated that patients with a suprapubic catheter experienced less pain and discomfort than the urethral group and the suprapubic catheter was preferred by those patients who had experience with both. In addition the ability to attempt normal voiding is enhanced with the later. There is also evidence to suggest that suprapubic catheters are better than indwelling urethral catheters in term of bacteriuria, need for re-catheterization and discomfort. The risk of developing bacteriuria from a catheter increases by 3-6% per day with the urethral catheter. This would mean that by 7 to 10 days the risk would increase to 50%.
Suprapubic catheterization is a standard procedure performed routinely in urological practice for other indications. The anticipated adverse events include blocked catheter, slippage and displacement of catheter. Displacement is a rare event and can be remedied simply by placing a urethral catheter with no consequences to the final result.
Other problems associated with indwelling urethral catheters include encrustation of the catheter, bladder spasms resulting in urinary leakage, hematuria and urethritis. A suprapubic tube is more patient-friendly, with no risk of urethral damage. Bladder spasms occur less frequently and suprapubic tubes are generally more sanitary. They may also cause fewer urinary tract infections than standard urethral catheters. Thus the benefits of the suprapubic route are reduced infection, control and monitoring of return of normal voiding, reduced need to recatheterize, avoidance of possible urethral damage and improved patient satisfaction. Drainage tubes using the suprapubic route however have a major drawback since this alternative to a urethral catheter does not splint the anastomosis, thus increasing the risk of bladder neck contracture.
Postoperative urethral catheterization is often a source of major discomfort and pain to the patient and may cause more concern to the patient than the procedure itself. Less invasive robotic radical prostatectomy has emerged as a commonly utilized surgical procedure in the management of clinically localized prostate cancer. Patients choosing this procedure are usually driven by its cosmetic benefits, earlier continence, shorter recovery time and minimal blood loss. However, despite the smaller incisions, early ambulation and shorter hospital stay, a few patients, especially the younger ones, continue to complain about the urethral Foley catheter remaining in place for extended time periods. Patients tend to experience urethral discomfort, penile tip pain and meatal encrustation and irritation due to the indwelling catheter. Despite postoperative recovery being essentially uneventful and smooth, patients continue to focus on the catheter and complain—“I wish you did not have to place a urethral catheter . . . ”